Provider Demographics
NPI:1639621857
Name:OTTENBREIT PSYCHOTHERAPY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:OTTENBREIT PSYCHOTHERAPY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:OTTENBREIT
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, ASCW
Authorized Official - Phone:313-575-6297
Mailing Address - Street 1:835 MASON ST
Mailing Address - Street 2:B-200
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2231
Mailing Address - Country:US
Mailing Address - Phone:313-575-6297
Mailing Address - Fax:313-406-4617
Practice Address - Street 1:835 MASON ST
Practice Address - Street 2:B-200
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2231
Practice Address - Country:US
Practice Address - Phone:313-575-6297
Practice Address - Fax:313-406-4617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMSW-68010076031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12313056OtherQAQH